title: Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study.
abstract: BACKGROUND
  Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group.
  
  
  METHODS
  Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed.
  
  
  RESULTS
  A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure.
  
  
  CONCLUSIONS
  On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.
authors.affiliation: Department of Surgery, University of Nebraska Medical Center, 985126 Nebraska Medical Center, Omaha, NE 68198-5126, USA.
authors.forename: Anton
authors.initials: A
authors.lastname: Simorov
authors.forename: Ajay
authors.initials: A
authors.lastname: Ranade
authors.forename: Jeremy
authors.initials: J
authors.lastname: Parcells
authors.forename: Abhijit
authors.initials: A
authors.lastname: Shaligram
authors.forename: Valerie
authors.initials: V
authors.lastname: Shostrom
authors.forename: Eugene
authors.initials: E
authors.lastname: Boilesen
authors.forename: Matthew
authors.initials: M
authors.lastname: Goede
authors.forename: Dmitry
authors.initials: D
authors.lastname: Oleynikov
mesh_terms: D042101:Acalculous Cholecystitis / Q000453:epidemiology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D002763:Cholecystectomy / Q000379:methods*; D002767:Cholecystostomy / Q000379:methods*; D016638:Critical Illness; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D016017:Odds Ratio; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
keywords: Acalculous; Cholecystectomy; Cholecystitis; Cholecystostomy; Laparoscopic; Outcomes assessment